Open treatment for lateral tennis elbow good for certain indications

In general, we try not to operate on tennis elbow until 6 months to 1 year after presentation because usually within a year about 90% of people will resolve their symptoms.

In the long-term, some 30% to 40% of people with epicondylitis symptoms may have a recurrent event beyond that point but most people will get over it.

Mainly we consider operative intervention for patients who are unable to perform sports or work activities. We used to say that if they had pain, calcification on X-rays and failed more than three injections, then it was time for operative treatment. The former two prerequisites still apply, but I no longer use steroid injections.

Open debridement

I do not routinely use injections for tennis elbow. There is clinical evidence that injections work for a short period of time; 50% are better at 6 weeks. However, if you look at the results, at 6 months, 9 months and 1 year, there is not much difference between the noninjected patients and those receiving the injections. I reserve injections for patients who have too much pain to do their exercises.

Hill Hastings II

Open debridement allows you to directly visualize what is going on in the elbow. If you have a large extensive lesion, open debridement allows you to better close over the lesion. It is the preferred treatment for recurrent cases, patients with post-treatment infections and those with radial tunnel syndrome instability. In my hands, it is quicker and less expensive.

Drawbacks to open lateral debridement include a possible slower recovery. Although we do not have good science, there are reports that patient recovery, in the first 3 weeks, may be a little slower, but that after 3 weeks the results are similar. It does leave an incision or scar and your ability to deal with intra-articular pathologies is limited to the lateral area you are exploring.

Costs

In terms of cost of open debridement and arthroscopic treatments, in our hands, if you look at the additional supply of arthroscopic equipment, independent of just basic suture kits, it costs about twice as much to do an arthroscopic than a simple open debridement.

Some key points to consider with an open procedure:

• Know where the lesion is. There are good landmarks and it is absolutely essential you know how to reproducibly find the lesion and also how to protect the lateral collateral annular complex; and
• Be assured that you have released the extensor origin, but do not violate a normal epicondyle. Some surgeons perform a lateral epicondylectomy to potentially promote improved vascularity However; I have seen patients who have had instability generated by this procedure. The procedure is worthless and triggers slower healing than by just debridement of soft tissues.

Some of the pitfalls of debridement include, you have to know where the extensor carpi radialis brevis (ECRB) distal origins are — the anterior face of the epicondyle; anterior to the midline of the radial head — correctly identify the lesion and debride distally enough. I excise the entire area of pathology. Also, do not miss the radiocapitellar pathology that may not be picked up by preoperative studies.

Results

There is not much data in the literature on results. The longest-term study was performed by Dunn, Davis and Nirschl who reported 76% good or excellent results by Nirschl criteria.

Everybody knocks down workers’comp, stating that you don’t have as good results with workers’comp-patients. An article by Balk and colleagues suggests that the results are the same with workers’comp and non-workers’comp populations. The main difference is that workers’comp group may not be able to get around some of the restrictions in their jobs, so change in a job is more common in workers’comp than non-workers’comp groups.

In comparisons of lateral open debridement and arthroscopic debridement, the only studies have been retrospective and suggest that the results are the same.

So, does it work? Yes, most of us think it does work. It does not lead to immediate improvement; it still takes 3 to 6 months to get over it even with surgery. Recognize that there are no controlled published prospective controlled studies comparing open treatment vs. arthroscopic for tennis elbow.

For more information

• Hill Hastings II, MD, is a clinical professor of orthopedic surgery at Indiana University Medical Center, Indianapolis Indiana. He can be reached at 8501 Harcourt Road, Indianapolis, IN 46260; 317-875-9105; e-mail: hh@hand.md. He has no direct financial interest in any products or companies mentioned in this article.

References:

• Balk ML, Hagberg WC, Buterbaugh GA, eta l. Outcome of surgery for lateral epicondylitis (tennis elbow); Effect of workers’ compensation. Am J Orthop. 2005;34(3):122-126.
• Dunn JH, Kim JJ, Davis L, Nirschl RP. Ten-to-14 year follow-up of the Nirschl surgical technique for lateral epicondylitis. Am J Sports Med. 208;36(2);261-266.
• Hastings H. Lateral tennis elbow: Open debridement. Precourse 9. Presented at the 63rd Annual Meeting of the American Society for Surgery of the Hand. Sept. 18-20, 2008. Chicago.